By Howard Markel © 2001 The New York Times Company
When Dr. Albert Tzeel left San Francisco for his first real job in an established Phoenix pediatrics practice in 1990, he expected that move to frame his life and career for decades to come.
In the last several months of his residency at the University of California, Dr. Tzeel had taken on moonlighting work to earn the down payment for a house. He and his wife decided to start a family, and they encouraged their parents, who were retired in Michigan, to move to Arizona for the warm and sunny climate.
But things did not work out as he had hoped, and in less than a year he was searching for a new job. Since leaving Arizona, Dr. Tzeel has had four different professional positions. He is hardly unique. With more and more doctors working in managed care settings, job turnover is at an all-time high. Medical journals are filled with advertisements of new employment opportunities, and every day physicians across the nation receive queries from medical headhunters.
Dr. Howard Kirz, a retired physician and consultant who helps disgruntled doctors find new positions, notes that in the decades before managed care relatively few doctors ever changed jobs once establishing a foothold. “Prior to 1990, about 1 to 2 percent of all practicing physicians changed jobs during a 20-year work career,” he said.
But since the early 1990’s, a number of studies have documented that more than 10 percent of the physician work force changes jobs annually.
The nomadic career path of today’s physicians is caused in part by professional dissatisfaction, unwelcome intrusions on how they can practice medicine and diminishing job security that has long been a fact of life for most working Americans but has only recently become one for doctors.
Dr. Sharon Buchbinder, an associate professor of health sciences at Towson State University in Maryland, said: “Older doctors are riding out these changes and waiting to retire. Middle-aged physicians are angry that the rules have changed so markedly in midstream, and a number of them are leaving medicine entirely. But it’s the younger doctors who are on the move.”
The average physician who has begun practice since 1990 is likely to have had three or four jobs by 2000, Dr. Buchbinder noted.
Physician turnover costs the health care industry untold hundreds of millions of dollars per year and has the potential to harm patients. The recruitment and replacement costs for primary care physicians average about $250,000 per doctor. It is even more expensive to recruit sub-specialists or doctors to practice in rural regions and impoverished urban areas.
Financial losses are also incurred when patients do not re-enroll in health maintenance organizations with high physician turnover rates. Problems also occur when primary care doctors take other jobs and leave behind patients who have grown to depend upon them.
“Physician turnover threatens health care quality because it deprives patients of consistent caregivers who know them well and will serve as their advocates,” said Dr. John M. Eisenberg, director of the Agency for Healthcare Research and Quality at the Department of Health and Human Services. “Research shows that patients who have a usual source are more likely to receive adequate preventive care and other health care services.”
Dr. Eisenberg also notes that patients with established and trusting relationships with their doctors are more likely to comply with complex medical and healthy lifestyle regimens.
Although Dr. Tzeel began his career in private practice, economic pressures pushed him toward jobs at two different H.M.O.’s. He soon grew dissatisfied with his role as a primary care physician in a large corporation and went back to graduate school to gain credentials as a physician- manager. He has since been a medical director for the Health Alliance Plan of Michigan and is now in a similar position at Humana of Milwaukee.
Dr. Tzeel admits to being naïve as a medical student.
“I had no concept of the intricacies involved with the business of medicine,” he said. “When I began private practice, I thought all I had to do was practice excellent medicine and keep my patients happy. In the employed setting, I not only had to keep my patients happy, I also had to see them quickly and in a cost-efficient manner.
“As I shifted into a management role, there was a different type of accountability in how each practice and the entire health network of clinics functioned. Each position has had its own unique rewards, stresses and drawbacks.”
Dr. Andrew Metinko, an intensive care specialist, has had an equally peripatetic professional journey. Initially an instructor at the University of Michigan, he ventured east for an assistant professorship at the Yale medical school.
Frustrated by the academic world and tempted by an opportunity to run his own intensive care unit, Dr. Metinko left Yale after two years to become director of pediatric intensive care at the Henry Ford Hospital in Detroit, the flagship of a large Midwest H.M.O.
He soon became disenchanted with the bureaucracy he encountered there and the lack of autonomy and resources he felt were essential to practicing quality medicine.
After a series of physician layoffs at the hospital, he looked for another job and ended up at Harborview Medical Center in Seattle. More recently, he began taking classes on the business of medicine.
“I realized that I needed to become facile in the language of health service management as well as its broader context to understand hospital operations, administrative decision-making and, hopefully, to help influence institutional and regional health care policies I must work under,” Dr. Metinko said.
Now, added Dr. Howard Horowitz, vice president of the American College of Physician Executives, many doctors are beginning to understand that jobs are not permanent, and they must prepare for that.
“As I see it today, the business of medicine is first a business,” Dr. Horowitz said. “Today’s health care industry is framed around powerful forces such as corporate integration, cost cutting, mergers and acquisitions, and attempts to reduce the number of health care providers at less successful managed care organizations. As good as a clinician a particular doctor may be, sometimes the circumstances of the marketplace gang up on him.”
Dr. Eisenberg said physicians were not simply frustrated with the industry changing around them.
“Frustrations with practice have always existed, and managed care is just a new wrinkle in an old problem,” he said. “One of the signs of success in the business world is changing a job every two years. Part of the job turnover phenomenon in medicine today may be ascribed not only to job dissatisfaction but also the phenomenon of being a successful employee.”
Dr. Buchbinder disagrees with this assessment. “Most doctors who move from job to job are looking for a better fit,” she said. “Salaries and job titles are only a part of the mix. Far more important factors include whether these doctors feel respected by management, the quality of care delivered by that H.M.O. and what type of corporate or financial constraints are imposed on their practice.”